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Rethinking TraditionalHealthcare Models:

Integrating TelecareTechnologies as Core

Elements ofCare Delivery

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Kevin Fickenscher, MD

Boston, Massachusetts

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A Brief Overview of theForces PrecipitatingChange in AmericanHealthcare Technology as a

Transformational andDisintermediating Force Why Telecare? A Framework… Results To Date

The Session…

“You never changethings by fighting

against the existingreality. To changesomething, build a

new model thatmakes the old model

obsolete.”

F. Buckminster Fuller

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“The real voyage ofdiscovery consists not offinding new lands but ofseeing the territory withnew eyes.”

- Marcel Proust

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The Premise… Society is demanding for all goods and services but –

especially for health care – that we…- ↓ Costs- ↑ Quality- ↑ Service

The inherent incentives of the health care industry aredisparate, inconsistent and dysfunctional – causingleaders significant challenges Society is moving inextricably towards an information

democracy rather than professionally dominatedtheocracy

= Focal point for health care change= Appropriate management of information required= Intellectual capital of medicine= Simultaneously empowering (consumers) and disempowering

(physicians)

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The Most CriticalQuestion!

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Why?

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Technology

Incentives

Expectations

Communications

Reasons for the Change…

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AmbCare

Traditional:Acute and Ambulatory Care Focus…

Acute

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10% OF AMERICANS RESPONSIBLE FOR 86% OF SPENDING

Where To Focus?

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Preventive

Acute SNF

HospiceAlt Living

Remote Patient MonitoringTransition

ChronicAmbCare

The Alternative:Comprehensive Coordinated CARE

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ClinicalHealthcare

HealthcareSystem

AppliedComputer

Sciences andTechnology

Source: Gardner RM, Overhage JM, Steen EB, et al. Core content for the subspecialty of clinical informatics. J Am Med Inform Assoc. 2009;16(2):page 154.

= the coordinated,real-time

application and useof technology and

analytics in thecare delivery

process

So, What Is Telecare?

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Telehealth = an over-arching description for the broad array of generic services,education and information using technology rather than face-to-face or hands-oninteractions between an individual and a care provider – such as: remote doctor-patientconsultations (telemedicine), remote monitoring of blood pressure, capture of ECG orvital sign data, and health education services

Telemedicine = refers specifically to the provision of interactive healthcare servicesand education by licensed healthcare professionals through the use oftelecommunications technology to and from a variety of locations

Telecare = the active involvement and engagement of a care delivery team in theprovision of services to individuals with acute and/or chronic illness through theappropriate and effective use of remote tele-management technologies includingproactive, remote care management in various environments including the home,skilled nursing facilities and other non-traditional care units

Splitting Hairs TeleWhat?

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The Tele–Intersection

FocusedAV

Education

IVRAmbientAssisted

Living

InteractiveCall

CenterSupport

IntegratedAnalytics

eVisits

RemotePatient

Monitors

SensorTracking

PatientNavi-gator

Onsite &RemoteAssess

Guideline&

ProtocolsMgmt

AlertsMgmt

CallCenter

Support

Telecare TelehealthRemoteLifestyleMonitors

Triage&

911

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Hospital Readmission Costing $26B Annually 13.6M Patients Over 65 Discharged from Hospital each year 2. 7M (20%) are Readmitted within 30 days of leaving

Poor Discharge Planning / Care Coordination is at Fault Main cause of readmission, especially health attacks and pneumonia $17B preventable if patients received right care

$10K $1K$9K

Avg MedicareCost per Patientper Admission

$20K

Doctor’s OfficeInstitutions

Home

HomeHospitalsLocations

Source: AHRQ

The TeleCare Focus

Telecare…Focusing On Care We Ignore

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PATIENT FRUSTRATIONThe “Transference Effect” of Technology in Other Industries Coming to Healthcare

(Travelocity, Amazon, Open Table)

US CLINICAL WORKFORCE SHORTAGEFewer Doctors, Nurses, Clinicians

To Handle These Patients

PATIENT & PROVIDER FACTORS

A PIPELINE FILLED WITH BABY BOOMERSHighly Complex, High Risk Patients Coming

Will Explode Medicare Costs Without Change

Telecare Drivers…

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Source: http://img.medscape.com/article/836/971/836971-figure.jpg

FINANCIAL INCENTIVESHospital-to-Home Transition ReimbursementRemote Care Coordination Reimbursement

SEARCH FOR EFFICIENCY AND EFFECTIVENESSProviders Seeking Approaches to Reduce Operational

Costs and Improve Efficiency

Telecare can replace…Telecare Drivers…

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Source: http://img.medscape.com/article/836/971/836971-figure.jpg

Telecare Drivers…

FINANCIAL PRESSURERapidly Changing Reimbursement Models

With Financial Penalties for Poor Outcomes

RISK SHIFTING FROM PAYERS TO PROVIDERSMore Accountability for Care Delivery Utilization and

Outcomes

Telecare can replace…

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Telecare…Not An Option, But An Imperative!

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Payment

Focus

Role of theProvider

Incentives

Volume-Based Value-Based

Information

The TheOld World New World

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FOCUS FOR TODAYAreas of Greatest Need and Impact Ambulatory Post-Acute Transition Chronic Illness

FOCUS FOR TOMORROW Non-Hospital Chronic Illness Chronic Illness Prevention Social Interventions Self-Care Management

Changing The Focus To Capture The Greatest Value

Refining The Focus…

CARE

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GAINING TRACTION

Source (Adoption Model): Bohlen, Beal and Rogers, Iowa State University

Critical factors towin over

early adopters

Telecare Is Moving From Early Adoption To Early Majority

Telecare Adoption Trends…

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COMPLEX CHRONIC DISEASE A KEY AREA OF FOCUS

Shifting From Acute To Chronic Care…

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THE CRITICAL NEED: MAPPING THE CARE DELIVERY PROCESS

ACUTECARE

POST-ACUTECARE

TRANSITIONCARE

CHRONICCARE

The Critical Point Of Integration…

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Timely access to actionable information for betterpatient care management

Knowing what is going on with a patient’s course ofcare, in between visits – when he or she is notphysically with the clinician

Detecting pre-acute conditions before the patientclinically decompensates

Not waiting for the patient to show up in the ER beforeknowing that a patient is trending in the wrongdirection

Advantages Of Telecare…

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Robust infrastructure supporting interoperable clinicalinformation exchange

Remote data capture of biometric, location and otherinformation via bluetooth enabled capability

Patient engagement technologies and services thatsupport the individual as well as family members

Real-time clinical call center support services withpatients assigned to specific nurses and clinicalsupport personnel

Management of care delivery via defined protocolswith active outreach “as needed”

Use of predictive analytics to modify and enhancecare delivery over time

Requirements For Effective Telecare…

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What we need is aComprehensiveCoordinatedCARE or… C2CARE

Framework

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Patient ProgramsIntensive Care Management

Super-Utilizers (top 5%)Episode Care Management

Acute Care StayChronic Care Management

10 Chronic ConditionsPalliative/End of Life Management

Provider/Patient EducationPopulation Health

Care Gaps

Coordinated Care TeamsClinical - Nurse

Social/Behavioral - Social Worker,Health Coach/Navigator

Community Health WorkerSupport: Pharmacist, Dietitian

Patient ProcessPatient Selection

ADT Alerts in ER or HospitalReferral Based on Qualification Criteria

Predefined Patient RegistryPhysician Authorized Referrals

Intake ProcessPatient Assessments (Onsite, Remote)

Patient Intake DecisionPatient Program & Services Assignments

Triggered Events & ProtocolPatient Registry (Who has triggers? Which ones?)Triggers (Emergency, patient concerns, transitions)

Notification (Who? How? When?)Associated Action (Remote Triage, 911, eVisit, etc.)

Escalation (Who? How? When?)Patient Monitoring

Ensure Actions - Referrals, transitions, emergenciesMonitor Patient Progress/Care Pathways

Patient Services(Online, Onsite, Remote)Behavioral Health Care

Care Management – Clinical, Social,eVisits (Clinical Consults)

Financial CounselingHome Assessment

Medication ReconciliationMobile Health Formulary

Patient Assessments (Online, Onsite)Patient Education (Online, Onsite)

Patient Empowered Care DecisionsQualified Options Development

Patient NavigatorRemote Patient Monitoring

SNF CoordinationTechnology Setup and Support

Technology PlatformAnalytics Device Support Patient Registry

Care Coordination Workflow Electronic Medical Record (EMR) Portals (patient, providers, etc.)Communications (encrypted texts) HIE (ADT Alerts, CCD, Quality data) Reporting & Distribution

Shared Savings Program Management GovernanceContract Management (ACO, Bundles) Provider Engagement Decision making, issue resolution

Perf. Monitoring (providers, outcomes) Care Advisory Board Utilization ManagementShared Savings Calculation, Baselines Training/Patient Workflow Patient Documentation

TPA – Gain Share Program/Distribution Referrals, Escalation, contacts ACO Quality Measures (33)/Patient Sat.Patient Outcomes Reporting/Regular updates What’s documented? Who? Shared? How?

Telecare Design Overview…

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Clinical

Social and Behavioral

Basic Needs

Coordinated CareManagement

Patient Outcomes

Shared Savings

Alignment

Care Decision Making

Based on Patient Recovery Factors – http://patientrecovery.org/index.php?title=Patient_Recovery_Factors

Get to know the patient, their needs; thenbuild a care system around them

What Is C2CARE?

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FinanceCounse

l

Care Delivery Information (CDI) Exchange Platform

Remote Patient MonitoringInteractive VoiceRecognition

Interactive ClinicalSupport Services

Patient and Family/Care Provider Engagement

24x7RemoteM

DServices

In-HomeNursingService

Discharge

Planning

PatientEducation

IntakeAssess

HomeAssess

MedsRecon-cilliation

SocialServices

Program Management and Coordination

A Framework forComprehensive Coordinated CARE

(C2CARE)

Analytics Services

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What is theC2CARE Framework?The model provides an approach for supporting thetransformation of the care delivery process withmobile services that use…iNDIVIDUALLY focusediNFORMATION to radicallyiMPROVE healthcare withiNNOVATIVE and

iNTELLIGENTiNTERVENTIONS

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What are the elements of theC2CARE Framework?

Continuity – the provision of services over time by professional CAREcoordinators who serve as extensions of the traditional care delivery providers

Adherence – the use of client approved guidelines and protocols provide afoundation of care delivery that integrates with ongoing workflow of theCARE delivery organization

Results – monitored, measureable outcomes in the care delivery processresult in enhanced services, greater satisfaction, increased quality andreduced costs in the CARE delivery process

Effectiveness – the ability to successfully and continuously produceintended outcomes in the CARE delivery process

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Nearly 2,000 studies in last six years describing resultsfrom the application of various technologies supportingremote care

Several hundred specific each to Diabetes, COPD, HeartFailure, Psychiatric applications, and tele-rehabilitation

But, <10% well-crafted RCT studies Wide range of interventions have been reviewed

• Televideo to supplement in-person encounters• On-line disease literacy applications• Inclusion of store-and- forward biometric monitoring

devices into clinical workflows• Interactive text messaging applications• Interactive Voice Response applications to solicit self-

reported symptoms and behavior data

TelecareLiterature Results…

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Majority positive:

Decreased mortality Improved biometrics (reduced risk) Improved QOL and satisfaction Reduced utilization (admissions, ER use, SNF use,

other unplanned care) Reduced readmissions Reduced lengths-of-stay Reduced costs Productivity increases (mostly increased touches) Improved disease literacy Equivalent efficacy as face-to-face care Improved quality metrics (HEDIS, STARs)

TelecareLiterature Results…

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Not enough ask about productivity

Most results relatively short term (median durationof 6 months or less)

Very few studies on cost-effectiveness

Formal studies under optimal conditions shed littlelight on real-world practice

Scant information provided on the craft of telecaremanagement

Telecare ResultsSome Deficiencies…

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Graham, J. et. al. Postdischarge Monitoring Using Interactive VoiceResponse System Reduces 30-Day Readmission Rates in a Case-

managed Medicare Population. Medical Care. Volume 50, No 1.January, 2012

Geisinger Health System

Threading IVR into transition of care best practices

Leveraging automation to extend RN reach

19.5% reduction in all-cause 30-day readmissions

44% reduced probability of any readmission (p<0.05)

ROI’s north of 6:1

Telecare Case Study #1Post-Acute Application

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Alrajab, S. et. al. 2012. A Home Telemonitoring ProgramReduced Exacerbation and Healthcare Utilization Rates in

COPD Patients with Frequent Exacerbations. Telemedicine ande-Health. December 2012, 18(10): 772-776.

Veterans Health Administration database of COPD patientsenrolled in Care Coordination Home Telehealth program.

N=1,133 COPD patients enrolled between 2005 and 2009.

Of 369 patients who had at least one exacerbation per year inthe year prior to enrollment, 71.5% had a reduction innumbers of ED visits and exacerbations requiringhospitalizations after enrollment in the program

Average number of hospital admissions, ED visits, and totalexacerbations were all reduced (p<0.01)

Telecare Case Study #2COPD Application

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McFarland, M. et. al. Use of Home Telehealth Monitoring withActive Medication Therapy Management by Clinical Pharmacists

in Veterans with Poorly Controlled Type 2 Diabetes MellitusPharmacotherapy. J. of Human Pharmacology and Drug Therapy

Vol. 32, Issue 5, pages 420–426, May 2012

103 Diabetics assigned to intervention or control

Messaging device used for interactive consults between MDs,pharmacists and patients

Pharmacists used data to adjust meds / relay information tocare managers for execution

Intervention group:• Significantly better HbA1c at 3 & 6 months (p<.001)• Higher percentage reached goals (p=.001)• More time spent with care managers overall (p<.001)• More Rx changes made (p<.0001)

Telecare Case Study #3ADiabetes Application: Acute Intervention

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Remote Monitoring of High-Risk Patients: TelehealthProtocols for Chronic Care Management profiles a

successful eight-year initiative by New York City Health andHospitals Corporation's (NYCHHC) House Calls Telehealth

ProgramHealth Information Network -

http://store.hin.com/product.asp?itemid=5008

Telecare Case Study #3BDiabetes Application – Chronic LT Mgmt

An innovative hybrid of technology and human touchpoints,over a two-year period

76% of 769 monitored patients experienced improved A1Csalmost every three months

All A1Cs over 13.1 were reduced to 10.2 – on average

91% of individuals with A1Cs between 11 and 13 experiencedan improvement

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Maeng, D. et. al. Can Telemonitoring reduce Hospitalizationand Cost of Care? A Health Plan’s Experience in Managing

Patients with Heart Failure. Population Health Management.August, 2014.

Geisinger Medicare Advantage Plan

N=541 CHF members tracked for 70 months (24 months onmonitoring)

Telehealth scales and IVR

Results• Hospitalization rate on RPM = 23% lower• 90-day readmission rate on RPM = 38% lower• 11.5% additional cost savings (3.3 to 1 ROI) – on top of the

pre-existing program

Telecare Case Study #4CHF Application

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TelePsych ApplicationChoi, N. et. al. Telehealth Problem-Solving Therapy for Depressed

Low-Income Homebound Older Adults. Amer. J. of GeriatricPsychiatry. Vol.22, Issue 3, March 2014

121 homebound individuals (scoring 15+ on HamiltonRating Scale for Depression) compared Tele-problemsolving therapy (PST) with In-Person PST and telephonesupport calls

In-Person PST = 6 sessions vs. Tele-PST = 2-6 sessionsvia Skype video call

HAMD scores of Tele-PST and In-Person PST participantsat 12-week follow-up = significantly lower than telephonesupport call participants + treatment effects maintained at24-week follow-up

No difference in HAMD scores for Tele- and In Person PSTparticipants

Telecare Case Study #5

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Commonalities of Successful Programs The technology per se can never be the focus. Programs

require putting accurate/meaningful information in front of theclinician – a synthesis of data.

Information gathering technologies will change with greatfrequency, information types far less

Remote care delivery must be embedded into the caremanagement workflow

Data informs and improves disease literacy

Real- or near-real-time data can drive physician and patientbehavior with positive interventions

Disciplined candidate selection criteria yields better results

Telecare Common Themes

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It’s the People and Process…Then theTechnology

Successful programs combined technology with humaninteraction

Very low-cost programs that rely on technology alone,are not always effective

People and Process costs more than equipment

The key is striking the right balance: Human touch to make the program effective Technology to make it efficient

Telecare Common Themes

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Outcomes in the literature show results across multiplecare delivery environments IF the requirements for

(C)2CARE are met…

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…use of aComprehensive

Coordinated CareFramework transformscare delivery through

the appropriateapplication oftechnology…

Decrease costs>35%

ROIs exceeding3:1

Reduce all-cause 30-dayreadmissions

Enhance caredelivery

efficiency

Improvebiometrics +reduce risks

Reduce hospitalALOS

Reduce requiredin-home nurse

visits >50%

Increase patientcompliance

>80%

Telecare Summary Results…

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IMPROVE QUALITY OF CAREIdentify issues, resolve them on timely basis

Better care management with real time information

REDUCE COST OF CAREAvoid unnecessary services and complications

Avoid inappropriate ER visits, hospital admissions, re-admissions

ENHANCE PATIENT SATISFACTIONHelp patients manage their chronic conditions

Provide a safe environment for “care” in the comfort of the home

44The Obvious Solution…Telecare

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• Leverage the capabilities of your organization to simultaneouslyimpact avoidable costs and improve outcomes.- Develop a “telecare” team- Focus on “process” and “people” – not technology- Expand your vision to include post-acute, transition and chronic care

• Ensure EMR use is effective in driving improved patient outcomes• Define value and track patient outcomes

- “Patient-centricity”- “Patient empowerment”- Education- Team capability- Partner selection and management

What Three Things To Do Right Away?

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Your Feedback?47

Discussion

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Kevin Fickenscher, MDPresident/CEO

(301) 540-0795 – Assistant: Susan Seiger(415) 450-1515 – Mobile